Rejection of surgery cover top ACC gripe

Refusal to pay for elective surgery topped the list of the 10 most common disputes over Accident Compensation Corporation decisions last year.

About 5600 formal reviews were taken by claimants against the state insurer in the year to June 2017, and ACC figures show 2330 of those complaints were over elective surgeries to treat injuries.

To reach a formal review, clients must appeal to ACC within three months of it making a decision to decline to cover the cost of a surgery.

The reviews are heard by disputes service firm Fairway Resolution. ACC’s decisions were upheld in 82 per cent of hearings in the year to June.

ACC specialist lawyer Warren Forster said the large number of surgery reviews was due to ACC declining so many elective surgery applications.

ACC received 51,270 claims to cover elective surgery in the past year.

Forster said claimants had already been told by a surgeon that ACC should pay, so to have it declined against a medical professional’s opinion was often surprising. ‘‘About 10 to 20 per cent who have a declined surgery review it.’’

ACC spokesman James Funnell said elective surgeries were often declined due to pre-existing conditions.

If ACC accepted a claim for elective surgery the claimant was placed higher on the hospital waiting lists and was entitled to lost income compensation while they recovered, he said.

‘‘There are significant benefits of having surgery approved by ACC, including earnings-related compensation while recovering, and reduced waiting times compared with the public health waiting list, so these are potentially drivers that contribute to the review rate for surgery decisions.’’

But those benefits were not factored into ACC’s decision to decline a claim.

The second most common reason claimants went to formal review last year was because ACC deemed that a direct cause for the injury could not be established.

More than 700 reviews contested ACC’s decisions for personal injury cover in the past year. ACC covers the costs of an injury if it was caused by accident, sexual violence, birth, or was the result of a gradual condition from working. Disputes over cover made up more than a third of this year’s top 10 reviews.

ACC claimants filed almost 600 reviews against refusal to pay for treatment, placing it fourth in the top 10.

There were 232 reviews on gradual process cover and 145 on accident cover, where the ACC refused to believe that injuries happened by accident.

Forster said those numbers were low compared to the average 50,000 cover claims that ACC declined each year.

ACC decisions to suspend compensation payments were the third most reviewed, and of most concern, he said.

Recipients had typically been receiving ACC payments for a long time. ‘‘ACC has had enough of these people.’’

Payments were typically suspended because the ACC found there was ‘‘no causal link’’ between a claimant’s injury and the reason for the payments.

Over the past seven years, the number of disputed decisions has almost halved – from 9800 in 2009 to 5600 last year.

ACC deputy chief executive Jim Stabback said the organisation tried to make as much information available to claimants as possible, to reduce the number applying for formal reviews.

‘‘We have been working for five to six years to drive it [formal review numbers] down … [But] there are incidences where clients feel it is necessary to review our decisions.’’